Thanks to our fearless leader Dr. Schroedl for presenting an interesting case of pulmonary MALT lymphoma!
Young woman with chest pain and dyspnea – left upper lobe lesion that didn’t respond to empiric treatment for CAP or even an empirical treatment for fungal pneumonia (unknown exact regimen). Bloodwork and noninvasive infectious workup were unrevealing. Initial bronchoscopy and biopsy were unrevealing. Repeat imaging six months later showed persistence of left upper lobe mass.
The patient got a repeat CT-guided biopsy that showed MALT lymphoma! This is a rare disease, and an extranodal low-grade B-cell lymphoma.
Treatment: ritxumab
The patient had good imaging response but persistent dyspnea, which is thought to be asthma that upon further probing, seemed present even prior to these.
Nice review article here: https://erj.ersjournals.com/content/34/6/1408
Thanks, Dr. Schroedl!
Clara Schroedl, MD, MSc, Medicine – Pulmonary/Critical Care
I usually think if an attempt at less-invasive tissue sampling doesn’t give an answer (here tbbx), time to move to a different method (VATS) although the long time interval in between does add an interesting wrinkle. Interesting repeat TBBx gave an answer. Any discussion on test characteristics of TBBX vs VATS for MALT (I still need to read review posted)
Great question, Mac! From the discussion of this (2009) review:
“Compared with older series most of our patients (71.4%) were diagnosed by minimally invasive procedures, including fibreoptic bronchoscopy, bronchial and transbronchial biopsies, and CT-guided percutaneous transthoracic biopsies. This minimal diagnosis approach seems justified as most patients had multilobar (61%) or disseminated disease (44%)”
There is a nice flowsheet in the review that shows the stepwise diagnostic approach in patients for whom less invasive approaches did not yield diagnosis